Esen Ibrahim Karakaya

Simultaneous reconstruction of medial canthal area and both eyelids with a single transverse split forehead island flap.

In this report, we are presenting a case in which we have split the paramedian forehead flap, thus providing 2 axially perfused skin flaps for simultaneous reconstruction of the upper and lower lid structures after resection of basal cell carcinoma from the left medial canthal area. We found that split forehead flap seems to be a favorable option for simultaneous reconstruction of the upper and lower eyelid defects by enabling nicely vascularized and abundant amount of regional skin.

Reconstruction of coup de sabre deformity (linear localized scleroderma) by using galeal frontalis muscle flap and demineralized bone matrix combination.

In this clinical report, we are presenting the combination of demineralized bone matrix combined with bilateral galea frontalis flaps. Based on our 6-month results, this seems to be a reasonable combination to accomplish long-lasting restoration of forehead defects related to en coup de sabre linear localized scleroderma.

Microsurgical training model for lymphaticovenous anastomosis in rat

Microsurgical training in rat models has been accepted as a vital step in educational process of achieving microsurgical skills? Currently, adequate and unique training models have been established for microsurgical dissection techniques, arterial and venous anastomosis as well as nerve repair and grafting techniques. These models have been developed in rats and include following applications: 1) the femoral and carotid arteries for arterial anastomosis trainning, 2) the femoral and jugular veins for venous anastomosis training, 3) sciatic nerve for coaptation for nerve repair trainning. These models can be extended for different technical applications such as end-to end, end-to-side, and sleeve anastomosis and interpositional vein grafting techniques. These techniques allow to build basic skills which are required to practice reconstructive microsurgery hand surgery, peripheral nerve surgery, and neurosurgery. Lymhaticovenular or lymphaticovenous anastomosis technique have revolutionarized the lymphoedema surgery by providing new approach for some difficult cases. This intervention is known as a ‘‘supermicrosurgical’’ technique and is considered as quite esoteric and unique microsurgical application due to low incidence of cases requiring such skills and due to lack of technical experience and expertise. Although these cases are not so commonly encountered by regular microsurgeon we believe that technique of lymphaticovenous anastomosis should be introduced in regular microsurgical training to prepare microsurgeons who can handle complex microsurgical reconstructions to be able to incorporate lymphatic vessel anastomosis if required. To fill this gap in microsurgical training we are presenting here a new training model for lymphatic vascular dissection and lymphaticovenous anastomosis in rat. We have used five Wistar rats in which we have dissected, and exposed thoracic duct and performed end to end anastomosis (two rats) to anterior facial vein and end-to-side anastomosis (three rats) to external jugular vein. During our dissections, surgical approach to thoracic duct in rat was a challenging step of the procedure, especially for a novice microsurgeon, thus it should be taken with caution involving following steps: Step 1: left side longitudinal skin incision starting from the mandible and extending to thorax. Step 2: excision of structures such as left submandibular gland, left sternocleidomastoid, and omohyoid muscle as well as the left clavicle. During these two steps, particular attention must be payed to meticulous dissection and retracting the branches of the external jugular vein within the neck fascia to prevent bleeding and opening of the external jugular vein. Step 3: identification of the subclavian vein and thoracic duct junction medially. Step 4: identification of common carotid artery. Step 5: following with sharp dissection from the thoracic duct–subclavian vein junction (lies adjacent to strap muscles overlying trachea) to the area just anterolateral to the carotid sheath (upper segment). After identifying the junction of thoracic duct and subclavian vein we had observed the physiological reflux of blood pulsating from the subclavian vein to the thoracic duct. During dissection white hue of the brachial plexus fibers were visible under the neck fascia. After ex*Correspondence to: Ilker Yazici, M.D., Kirikkale Üniversitesi Tip Fakültesi, Plastik Cerrahi Anabilim Dali Saglik Sok. Fabrikalar Mah, 71100, Kirikkale, Turkey. E-mail: ilkeryazici@gmail.com

Hypertrophic frontal sinus reduction by using anterior wall internalization and galeal frontalis flap obliteration.

In this article, we are introducing the use of galeal-frontalis flap to reduce hypertrophic sinus based on 1 case: a 25-year-old amateur boxer who had prominent frontal area due to hypertrophic frontal sinus. Three-dimensional reformatted computed tomography scans were obtained for evaluation of the hypertrophy and the morphology of the frontal sinus. Reduction of the hypertrophic frontal sinus was performed by resection and shaping of the anterior wall and obliteration of the frontal sinus by right-side galeal-frontalis flap excision via bicoronal approach. The trimmed anterior wall was inserted into the frontal sinus and secured with three 3.0 PDS sutures to the bone edges, and the incision was closed. The outcome was satisfactory without any complications during 1-year follow-up, and sixth-month computed tomography scans revealed no bone resorption. Here we are introducing a novel technique to reduce hypertrophic sinus based on a clinical report.

The use of tissue expander in the management of staged proximal hypospadias repair: report of case

Multiple failed hypospadias reconstructions may cause minimal residual skin, as a result of extensive scarring. However, extragenital full thickness skin grafts or mucosal grafts are often used for urethral substitutions; local tissue expansion can provide additional matched skin, which can be easily harvested and used for penile constructions. Though tissue expanders were used as the choice of treatment in children with multiple failed hypospadias repairs, the use of tissue expander in the management of staged proximal hypospadais repair has not been reported previously. A 3-year-old boy with proximal hypospadias is presented to discuss the use of tissue expansion in the management of staged proximal hypospadias repair.

Methylene blue vital staining of nerve stumps in secondary peripheral nerve repair.

Adequate preparation of the nerve stumps prior to nerve coaptation or grafting is vital for obtaining satisfactory results in secondary peripheral nerve repairs. Resection of the posttraumatic neuroma is needed in order to get rid of the blocking fibrosis and reaproximate axonal tubes. Freshing the nerve edges and resection of the neuroma must be performed with precision in order to minimize the nerve gap and to reach healthy axonal tubes (preinjury segment). Well trained surgeon familiar to peripheral nerve structure and adequate magnification is needed for this purpose. As a secondary aid and a novel approach we are using vital methylene blue staining in order to confirm and documentize that we have reached the healthy nerve structure. Vital staining of nerves by methylene blue was first demonstrated by Ehrlich and used for research purposes and surgical purposes up to date. Intraoperative surgical vital staining of peripheral nerves with methylene blue was found to be an effective method in order to identify complex nerve structures for sparing during extensive procedures. Facial 2. Enables documentation of the surgical session and the extent of the injury by taking photos for legal purposes. 3. Enables documentation of healthy axons if exists in the case of neuroma in continuity for correlation with preoperative Fig. 1. Sequential photos of nerve slices starting from the tip of the stump. From slice-a to d intraneural fibrosis (depicted with arrow) diminishes. Arrow shows very little amount of fibrotic tissue persistent in slice-d. Slice-a includes no fascicular structure stained whereas slice-d reveals healthy fascicular structure.

Use of dental mirror in microsurgical practice.

In this article, we introduce the use of dental mirror during microsurgery. We have been using no. 4 dental mirror during microvascular anastomoses and nerve coaptations for the last 6 months successfully and found that, as a cheap and easily obtainable instrument, it has facilitated our practice. We are strongly recommending the use of dental mirrors in microsurgical practice and inclusion to every microsurgery instrument set.

Compass cutter for periareolar incisions.

Proper instrumentation is essential for better practice in plastic surgery. Proper instruments can standardize procedures, ease applications, decrease and sometimes eliminates human errors. An important example of the need for specialized tools in plastic surgery practice is the circumareolar incision in reduction mammaplasty or mastopexy procedures. The circumareolar incision is an important part of the procedure because it directly affects the newly formed areola size and shape. To date, many techniques and tools have been developed and widely used [1,2]. These include templates in different diameters for marking, commercially available cookie cutters, and frankly, in some instances, bottle caps with certain diameters. The most important problem with these tools is the necessity to obtain the instrument with the desired diameter for the patient. To solve this problem, we use the Compass Cutter/ Knife (OLFA, Osaka, Japan) (Fig. 1), which is sterilized in ethylene-oxide. The diameter of the circle to be created can be set to 1 to 15.2 cm. Although the ideal areola size is also related to the nipple diameter and breast size, acceptable nipple diameters range from 38 to 45 mm [3]. Under precise tension applied to the nipple– areolar complex by the assistant, this cutter can be used by centralizing its pin to the center of the nipple. By turning the compass clockwise, it is possible to prepare the circumareolar incision (Fig. 2).